Transluminal coil embolization of an inferior gluteal artery aneurysm by ultrasound-guided direct puncture of the target vessel.

Pseudoaneurysms of the inferior gluteal artery are rare. We describe a case of an inferior gluteal pseudoaneurysm that presented as a painful mass in the buttock. A percutaneous thrombin injection under ultrasound guidance failed to occlude the sac, probably due to the wide neck of the aneurysm. Subsequently, transluminal coil embolization by ultrasound-guided direct puncture of the inferior gluteal artery achieved complete thrombosis of the sac. Ultrasound-guided coil embolization is recommended in the treatment of peripheral aneurysms where catheter placement using conventional interventional procedures is difficult.

Pancreaticoduodenal artery aneurysm: a case report and review of the literature.

A case of true pancreaticoduodenal artery (PDA) aneurysm is reported. A calcified lesion was initially detected by plain x-ray films, and an essential diagnosis was made before operation by intravenous digital subtraction angiography (IVDSA). Surgical resection of the aneurysm was performed successfully. Additionally, we reviewed a total of 82 cases with PDA aneurysm out of the 88 cases that had been reported in the English-language literature up to 1993. Fifty-three cases were accompanied by aneurysmal rupture (rupture group), and 29, including our case, were without rupture (nonrupture group). Because of the high mortality rate (49.1%) in the rupture group, a precise diagnosis and adequate treatment of PDA aneurysm before rupture is important. In the nonrupture group, a calcification on radiography appeared in 61.6% of the cases in which aneurysms were not found incidentally; this seems to be a significant indication for angiography. Moreover, intravenous digital subtraction angiography is quite useful for the screening of PDA aneurysm because it is an easy and noninvasive examination.

Internal biliary drainage, unlike external drainage, does not suppress the regeneration of cholestatic rat liver after partial hepatectomy.

We previously showed that hepatic cells proliferate in obstructive jaundice alone without partial hepatectomy and found that external biliary drainage for obstructive jaundice markedly suppresses liver regeneration after partial hepatectomy. In this study, we produced a model system for internal biliary drainage in which bile was drained into the stomach of rat fed a liquid diet. The regeneration capacity of the liver was assessed on the basis of the induction of DNA polymerase-alpha activity, as well as the mitotic index of hepatic cells. A remarkable difference was observed in the regeneration capacities of cholestatic livers between two groups--one in which jaundice was released by the internal and one by external biliary drainage before hepatectomy. After 5 days of internal biliary drainage, the regeneration capacity remained at a level comparable to that of sham-operated control rats, in sharp contrast to the impaired regeneration after external biliary drainage. These results clearly indicate that internal biliary drainage is preferable for release of biliary obstruction before partial resection of cholestatic liver.

Cholangiocellular carcinoma in the caudate lobe with intraluminal growth in the extrahepatic bile duct.

A case of cholangiocellular carcinoma in the caudate lobe with intraluminal growth in the extrahepatic bile duct is reported. The main tumor in the caudate lobe was detected by computed tomography and angiography, and two intraluminal tumors at the hepatic hilus and at the root of the right posterior segmental duct were well demonstrated by cholangiography and percutaneous transhepatic cholangioscopy. Independent total caudate lobectomy with bile duct resection was performed. Cholangiocellular carcinoma of the liver with intraluminal growth in the extrahepatic bile duct is very rare and has not been reported in the literature. Independent caudate lobe resection requires a rather complicated technique. However, this method has the advantage of reducing to a minimum the hepatic volume to be resected, and is useful for poor-risk patients or for cases with localized carcinoma at the hepatic hilus.

An unusual growth pattern of a mucin-producing intrahepatic cholangiocellular carcinoma involving the hepatic hilus.

The case of a mucin-producing intrahepatic cholangiocellular carcinoma in a 73 year-old-man is presented. A tumor originating in the right posterior inferior segment of the liver was found to be invading the right posterior and anterior bile ducts, and the hepatic hilus. Extensive superficial spread was observed in the entire posterior segmental bile duct extending to the hepatic hilus. Mucin produced and excreted by the tumor was retained in the common hepatic and common bile duct. The diagnosis in this case was suggested by percutaneous transhepatic aspiration of mucinous bile, and was confirmed by utilizing the techniques of ultrasonography, percutaneous transhepatic cholangiography, computed tomography and angiography. Curative surgery, which included right hepatic lobectomy with total caudate lobectomy and bile duct resection, was performed. Biliary continuity was maintained by left hepaticojejunostomy using a Roux-en-Y jejunal loop. The histological diagnosis was mucin-producing papillary adenocarcinoma originating in the right posterior inferior segment of the liver. Postoperative recovery was very good and the patient has now been enjoying a good active social life for the last 20 months with no signs of tumor recurrence. This case report discusses the unusual growth pattern of a mucin-producing intrahepatic cholangiocellular carcinoma involving the hepatic hilus, and suggests rational surgical treatment.

Decrease in regeneration capacity of rat liver after external biliary drainage.

In order to discover the effect of external biliary drainage on liver regeneration, we have produced a model system carrying cannula in the common bile duct of rat liver and examined the regeneration capacity of liver after partial hepatectomy under various conditions. Previously we have shown that hepatic cells proliferate by obstructive jaundice alone without partial hepatectomy [Terasaki et al; Jpn J Cancer Res 1991;82:170-175]. In the present study, we showed that DNA polymerase-alpha was induced by partial hepatectomy of rats suffering from obstructive jaundice and the induced level was similar to that of the normal regenerating liver. The level of DNA polymerase-alpha activity corresponded well to the liver regeneration capacity estimated by mitotic index. Contrary to our expectation, external biliary drainage for obstructive jaundice markedly suppressed the regeneration capacity of the remaining liver which was estimated by DNA polymerase-alpha activity, mitotic index and [3H]thymidine incorporation. The suppression may be due to the external biliary drainage itself because the liver regeneration of normal rats without jaundice was also suppressed by the biliary drainage. These results suggest that the external biliary drainage seriously suppresses the regeneration capacity of liver at least at the early stage of obstructive jaundice.

[Management of cholangitis complicated in biliary carcinoma with hilar bile duct stenosis].

We reviewed 60 cases of biliary carcinoma with hilar bile duct stenosis which had received percutaneous transhepatic cholangio-drainage (PTCD). Of the 60 cases, nine were complicated with acute cholangitis (AC) and three with segmental acute obstructive suppurative cholangitis (S-AOSC). The incidence of cholangitis was 20%. Six patients with AC and three with S-AOSC underwent hepatic resection for carcinoma. As to preoperative management for cholangitis in these 9 cases, conservative chemotherapy was effective in only 2 cases, and additional PTCD or segmental introduction of the drainage catheter under PTCS were useful in 5 cases. The remaining 2 cases with S-AOSC needed urgent hepatic resection including suppurative hepatic segments after various interventional treatments. No significant difference was found in resectability, morbidity and mortality between the cholangitis group and non-cholangitis group. In conclusion, it is emphasized that postoperative outcome of biliary carcinoma with cholangitis will be improved by adequate PTCD and/or urgent hepatic resection.

Carcinosarcoma of the esophagus: a twenty-case study.

The present report reviews results from 20 carcinosarcoma patients, and compares them with 773 cases of squamous cell carcinoma of the esophagus treated surgically at the National Cancer Center Hospital from 1971 to 1988. Although there were no significant differences in age, sex, symptoms or location between the two groups, the carcinosarcoma group had morphological characteristics as follows. (1) Seventy-five percent of the carcinosarcomas were of the elevated type. (2) The tumor was large. (3) The depth of invasion was limited to the esophageal wall in 80% of the carcinosarcomas. The rate of lymph node metastasis was almost the same, at greater than 65%, in both groups. Moreover, lymph node metastasis occurred at various stages, of the depth of invasion in the carcinosarcoma group. The curative resection rate was higher for carcinosarcoma (80%) than for squamous cell carcinoma (46.5%). There was no significant difference in recurrence rate between them. Compared with the high frequency of lymph node recurrence in the squamous cell carcinoma group, the recurrence due to hematogenous metastasis was more frequent in the carcinosarcoma group. Although the three-year survival rate was higher for carcinosarcoma (62.8%) than for squamous cell carcinoma (28.1%), there was no significant difference in the five-year survival rate between them (26.7 vs. 22.4%). In conclusion, radical esophagectomy with lymph node dissection is a necessary therapy for carcinosarcoma, and careful follow-up, paying special attention to hematogenous metastasis, is required.